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The frame used across this series: what the Court of Inquiry establishes, what is inference, and what the public record cannot answer.
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A reading of the New Zealand Defence Force Court of Inquiry into the grounding and loss of HMNZS Manawanui off Samoa on 5 October 2024, with an AcciMap of the causal structure the Court set out.
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Built in Norway in 2003 as the offshore vessel Edda Fonn, bought by New Zealand in 2018, and lost off Samoa in 2024. What changed when she became a naval ship, and what did not.
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Where the controls were on Manawanui's bridge, what they did, and what they told anyone. The autopilot switch sat beside the port pod; the autopilot drove the starboard one, from a console a metre and a half away.
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Between the misdiagnosis and the reef there were a hundred and twenty-two seconds, and the bridge team used them. Four correct actions, all of them nullified by one switch nobody touched — and a bridge card on which that switch was not item one.
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The loss drawn as a causal structure rather than a list. Rasmussen’s AcciMap stacks the decisions by the level that took them, and the right-hand column of the map carries the argument: causation runs vertically, accountability did not.
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SOLAS Chapter V Regulation 24 governs autopilot use in hazardous waters — and it did not apply to Manawanui, because warships are carved out of the Maritime Transport Act. Had it applied she would have passed one limb and failed the other, and still gone on the reef.
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The grounding rewritten as a risk analysis, in the structure a medical device file would use: thirteen hazards, each with its controls listed in order of strength — inherent safety by design first, information and training last — and a column recording which of them were present on the night.
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Three officers face court martial. The qualification document is still unwritten, the work-up still not completed, the supervisor’s role still commonly known rather than defined. A US warship doing the same work would have had a qualified hand on the wheel and an officer watching them do it; Manawanui had a cruising watch and no helmsman.
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Introduction The Court finds at ¶61(q) that the ship was "assessed to have been placed in autopilot mode" at 18:13:08. Placed is a transitive ve...
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The information problem Yacht readiness is an information problem. An information problem before an incident, and an investigation afterwards. You di...
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Why serious yacht owners need software that understands LOA isn't just a single number, but a multifaceted measurement that varies by context, certificate, and purpose.
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